Claremont | 08 9384 6855 Jandakot | 08 9414 1470

Coronavirus (COVID-19) Questionnaire

Coronavirus (COVID-19) Questionnaire

If you have been exposed to coronavirus (COVID-19), you may spread the virus to your Paediatric Dentist or Orthodontist, his team, or other patients/parents/visitors to the Practice. Therefore, prior to each appointment, we will be asking you to confirm answers to the following questions to reduce the chances of transmission of COVID-19 in our Practice. If you answer Yes to any of the Health Questions below, you will be asked to reschedule your next dental appointment to a later date.

Patient Details

Next Appointment Date:

Next Appointment Time:

Health Questions

Have you, your child, members of your family, others accompanying you to your next appointment or other recent acquaintances tested positive for, or been diagnosed as having Coronavirus (COVID 19)?
YesNo

In relation to you, your child, your family members or other persons accompanying you to your next appointment

Have you come into close contact (within 1.5m for more than 15 minutes) with someone who has a confirmed Coronavirus (COVID–19) diagnosis in the past 14 days?
YesNo


Do you have a fever (greater than 38 Degrees Celsius) or symptoms of a lower respiratory illness such as a cough, shortness of breath, difficulty breathing or sore throat?
YesNo


Do you have any other flu-like symptoms such as gastrointestinal upset, a headache or fatigue?
YesNo


Have you recently experienced loss of taste or smell?
YesNo


Do you have persistent pain, pressure, or tightness in your chest?
YesNo


Have you returned from travel overseas, interstate, a cruise ship or travelled outside the Perth metropolitan area in the last 14 days?
YesNo

Informed consent for dental treatment during the COVID-19 pandemic

I understand that COVID-19 has a long incubation period during which time carriers of the virus may show no symptoms and still be highly contagious. It may not be possible to determine whether someone has COVID-19 or not given current limits in virus testing. I understand that there is therefore a risk that a person attending First Smiles may be infected with COVID-19 and expose either me, my child or an accompanying person to COVID-19.
YesNo


In light of the known risks in relation to contracting COVID-19, I consent to me or my child (as relevant) receiving dental treatment at First Smiles during the COVID-19 pandemic period.
YesNo


We thank you for your understanding in implementing these measures which are designed to preserve your health and safety, that of our other patients and our team, and limit the community transmission of COVID-19. If you have any questions in relation to this COVID-19 Questionnaire and the protocols in place in our office, please email hello@firstsmiles.com.au or call us on 9367 9277.


We look forward to seeing you soon.